Anurag Goel ST5, Gastroenterology.
Definition: presence of free fluid in the peritoneal cavity
Caus uses es of of Asc scites ites Cause Frequ quency ncy Cirrhosis 81% Cancer 10% Heart Failure 3% Tuberculosis 2% Dialysis 1% Pancreatic Disease 1% Other 2%
Non-peritoneal causes Examples Intrahepatic portal Cirrhosis hypertension Fulminant hepatic failure Veno-occlusive disease Extrahepatic portal Hepatic vein obstruction hypertension (ie, Budd-Chiari syndrome) Congestive heart failure Hypoalbuminemia Nephrotic syndrome Protein-losing enteropathy Malnutrition Miscellaneous disorders Myxedema Ovarian tumors Pancreatic & Biliary ascites Chylous Secondary to malignancy, trauma
Peritoneal Causes Examples Malignant ascites Primary peritoneal mesothelioma Secondary peritoneal carcinomatosis Granulomatous peritonitis Tuberculous peritonitis Fungal and parasitic infections Sarcoidosis Foreign bodies (cotton ,starch, barium) Vasculitis Systemic lupus erythematosus Henoch-Schönlein purpura Miscellaneous disorders Eosinophilic gastroenteritis Whipple disease Endometriosis
Catego gory ry Infectious diseases Amebiasis, Ascariasis, Brucellosis, Chlamydia peritonitis, Complications related to HIV infection, Pelvic inflammatory disease, Pseudomembranous colitis, Salmonellosis, Whipple's disease Hematologic Amyloidosis, Castleman's syndrome, Extramedullary hematopoiesis, Hemophagocytic syndrome, Histiocytosis X, Leukemia, Lymphoma, Mastocytosis, Multiple myeloma Miscellaneous Abdominal pregnancy, Crohn's disease, Endometriosis, Gaucher's disease, Lymphangioleiomyomatosis, Myxedema, Nephrotic syndrome, lymphatic tear or ureteral injury. Ovarian hyperstimulation
Ultrasound with Dopplers ◦ Easily confirms ascites ◦ May see nodularity of cirrhosis ◦ Evaluate patency of vasculature ◦ No radiation, contrast CT / MRI ◦ Evaluation for malignancy
Grade 1 ◦ Mild, only detectable by U/S Grade 2 ◦ Moderate, symmetrical distension Grade 3 ◦ Gross or large with marked distension Large typically means painful/uncomfortable Refractory Ascites (5-10%) ◦ Can not be mobilized or early recurrence refractory to medical management NEJM 350:1646-54 Hepatology 2003; 38: 258-266
15cm lateral and 2 cms below umbilicus Avoid enlarged spleen and liver Avoid sp and inf epigastric arteries No data to support use of FFP Most clinicians would give pooled platelets if <40 Complication: ◦ Haematoma<1% ◦ Bowel perforation/haemoperitoneum <0.1% 10-20ml of fluid in a syringe with blue/green needle
Go 2cm below the umbilicus in the midline or 3 cm superior and medial to the anterior superior iliac spine www.uptodate.com
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Routi tine ne Optional nal Unusual Cell count and Glucose concentration Tuberculosis smear differential and culture, adenosine deaminase Albumin concentration LDH concentration Cytology Total protein Gram stain Triglyceride concentration concentration Culture in blood Amylase concentration Bilirubin concentration culture bottles
Is portal hypertension present? 97% accurate SAAG > 11 g/L Portal HTN SAAG < 11 g/L Other causes SAAG = (albumin concentration of serum) - (albumin concentration of ascitic fluid) The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites. Runyon BA; Montano AA; Akriviadis EA; Antillon MR; Irving MA; McHutchison Ann Intern Med 1992 Aug 1;117(3):215-20.
SAAG > 1 11 g/L (PORTAL RTAL HT) SAAG < 1 11 g/L Cirrhosis Peritoneal carcinomatosis Alcoholic hepatitis Peritoneal tuberculosis CHF Pancreatitis Massive hepatic metastases Serositis Budd Chiari Syndrome Nephrotic syndrome Congestive heart failure/constrictive pericarditis
1. Check serum SAAG > 11 SAAG < 11 and fluid albumin Hepatic Sinusoid source Peritoneum source 2. Check Ascites Ascites Protein <25 Ascites Protein >25 Ascites Protein >25 Capillarized sinusoid Peritoneal lymph Normal sinusoid Protein 3. Differential Cirrhosis Cardiac ascites Malignancy Diagnosis Late Budd-Chiari Early Budd-Chiari Tuberculosis Veno-occlusive disease The SAAG does not need to be repeated after the initial measurement. Note: Exceptions exist: may have mixed features Adapted from www.gastro.org
Is ascites infected? ◦ Greater than 250 PMN = SBP If ascites is bloody ( > 50,000 RBC/mm3), correct by subtracting 1 PMN / 250 RBC Is ascites bloody? ◦ 5% of pts w/ cirrhosis - spontaneous or s/p traumatic tap. Non-traumatic associated with malignancy ◦ 20% of malignant ascites ◦ 10% of peritoneal carcinomatosis
◦ Total protein >10 g/L ◦ Glucose <2.8 mmol/L ◦ LDH greater than serum ULN ◦ Low sensitivity + specificity however.
Consistent with infection or malignancy? ◦ Infection and cancer consume glucose low LDH is a larger molecule than glucose, enters ascitic fluid with difficulty. ◦ Ascitis/Serum LDH ratio ~ 0.4 in cirrhotic ascites Approaches 1.0 in SBP >1.0, usually infection or tumor
Amylase ◦ Uncomplicated cirrhotic ascites About 40 IU/L. The AF/S ratio is about 0.4 ◦ Pancreatic ascites About 2000 IU/L. The AF/S ratio is about 6 Triglycerides — milky fluid. ◦ Chylous ascites - TG > 200 mg/dL, usually 1000 mg/dL Bilirubin — brown ascites. ◦ Biliary perforation – AF Bili > serum Bili
Smear – extremely insensitive Culture – 62-83% when large volumes cultured Cell count – mononuclear cell predominance Adenosine deaminase – ◦ Enzyme involved in lymphoid maturation ◦ Falsely low in pts with both cirrhosis and TB
“almost 100%” with peritoneal carcinomatosis have positive cytology Malignant ascites from massive hepatic mets, HCC, lymphoma are usually negative Overall sensitivity for detection of malignancy-related ascites is 58 to 75 %
pH pH, lactate te, ‘ humoral tests of malignancy’ such as fibronecti ronectin, cholest ester erol. l.
No clinical data to back up the finding that upright position is asscociated with reduced GFR and reduced Na excretion and reduced diuretic efficacy Bed rest promote muscle atrophy and other complications and extends hospital stay So bed rest not recommended
Typical UK diet has 150mmol/day- 15% added salt and 70% is manufactured salt Suggestion is no added salt diet and avoidance of prepared food So that patient gets 90mmol/day ( 5.2gm) Lowers diuretic requirement, faster resolution of ascites and shorter hospital stay Avoid high salt content of fluid and medicine except in HRS
No role in uncomplicated ascites Most hepatologists restrict fluid in ascites associated with hyponatraemia- but is illogical The downside is water restriction causes increase in the central effective hypovolaemia- more ADH- more water retension and further dilutional hyponatraemia So hepatologist including the authors of the BSG guidelines suggest further plasma expansion to inhibit ADH secretion Data emerging supporting use of specific vasopressin 2 receptor antagonists To be effective the intake should be less than urine output rather than arbitrary 1.5L/day If the serum sodium concentration does not increase within the first 24 to 48 hours, the degree of fluid restriction has been insufficient.
Spironolactone is drug of choice Aldosterone antagonist acting in distal tubule to increase natriuresis and conserve potassium Initial dose 100mg and increasing up to 400mg Lag of 3-5days Better natriuresis and diuresis than a loop diuretic Antiandrogenic effect- gynaecomazia- tamoxifen 20mg bd Hyperkalaemia frequently limits the use
Frusemide has low efficacy in cirrhosis Use only if 400mg of spironolactone fails to achieve weight loss Start at 40mg a day and increasing by 40mg every 3 rd day to max of 160mg Watch out for metabolic alkalosis and electrolyte disturbance
Weight loss ◦ Loose 0.5kg a day when no edema ◦ Loose 1kg a day when edema is present Avoid renal failure Response rate in up to 90% patients who do NOT have renal dysfunction Dig Dis 2005; 23:30-38 Hepatology 2003; 38: 258-266
Over diuresis is associated with intravascular volume depletion, leading to renal impairment, hepatic encephalopathy and hyponatraemia 10% will have refractory ascites Dietary history to exclude salt ingestion- 24hr urinary Na excretion should be less than recommended intake Drug history - NSAID
Na 126-135 and normal Continue diuretic creatinine Do not water restrict Na 121-125 and normal Continue/? discontinue creatinine Na 121-125 and high Stop diuretic and give Creatinine volume expansion Na <120 Stop diuretic
Give only if renal function is worsening – creatinine >150 or 120 and rising Gelofusion/Haemaccel/ 4.5% albumin – all have 153mmol of Na per L This will worsen salt retention but better to have ascites than to develop HRS
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